Bariatric Surgery: A Shift From Buffet to Bar

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This study was designed to assess substance use before and after bariatric weight-loss surgery.

Note that the data suggest that patients who undergo laparoscopic Roux-en-Y gastric bypass surgery may be at increased risk for alcohol use following surgery.

An increased risk for substance abuse appears to be an unintended consequence of weight-loss surgery for some patients -- a risk that is apparent within 30 days of surgery.

The frequency of any substance use increased by 50% during the first 24 months after surgery, Alexis Conason, PsyD, of St Luke's-Roosevelt Hospital Center in New York City, and co-authors wrote in a study published online by Archives of Surgery.

Separate analyses of the individual components of the composite endpoint showed a significant increase in the use of alcohol and trends toward increased use of drugs and cigarettes.

The type of surgery significantly affected substance use, particularly alcohol, as patients who had laparoscopic Roux-en-Y gastric bypass initially had a significant reduction in the frequency of alcohol consumption followed by significant increases at 12 and 24 months. No interaction was observed between laparoscopic adjustable gastric banding and alcohol use, the authors wrote.

Acknowledging limitations that included a high attrition rate during follow-up, the authors nonetheless concluded that substance use occurred more frequently after weight-loss surgery.

"Based on the present study, undergoing Roux-en-Y gastric bypass surgery appears to increase the risk for alcohol use following weight-loss surgery," Conason wrote.

"Risks and benefits should be weighted when recommending laparoscopic Roux-en-Y gastric bypass surgery to patients who may be at increased risk of developing problems with alcohol after weight-loss surgery, such as those with a personal or family history of alcohol abuse or dependence."

Few studies have examined substance use after bariatric surgery, but one of those showed overrepresentation of post-bariatric surgery patients in substance abuse treatment centers.

Moreover, previous studies were limited by lack of baseline information about patients' substance use, the authors noted in their introduction.

One recent study examined substance use after bariatric surgery from a longitudinal perspective. Those data revealed an increased frequency of alcohol use at 1 and 2 years compared with presurgical levels. Alcohol use increased significantly only in patients who underwent Roux-en-Y gastric bypass (JAMA 2012; 307: 2516-2525).

Still more studies have shown that the brain responds in a similar manner to food, drugs, and alcohol, the authors continued. Moreover, individuals with binge-eating disorder display addictive tendencies similar to those of people with substance addictions.

Given the preceding background, Conason and colleagues prospectively evaluated substance use in 155 patients who underwent bariatric surgery: 100 who had Roux-en-Y gastric bypass and 55 who had adjustable gastric banding. Study participants completed the Compulsive Behaviors Questionnaire at 1, 3, 6, 12, and 24 months after surgery.

The primary endpoint was composite substance use, consisting of recreational drugs, alcohol, and cigarettes. At each follow-up, participants rated each type of substance use on a scale of 0 to 10.

The mean composite score increased from 0.81 at baseline to 1.25 at 24 months (P=0.02). In the first month after surgery, the score declined to 0.42 (P<0.05 versus baseline) but then increased at each subsequent follow-up, including a rise from 0.88 to 1.25 between 12 and 24 months (P≤0.002 for trend).

Among the individual components of the composite endpoint, only alcohol use increased significantly (2.29 at baseline, 3.10 at 24 months, P<0.05). However, recreational drug use (0.11 versus 0.45) and cigarette use (0.44 to 0.61) also increased from baseline to 24 months.

Analysis of the individual types of substance use revealed significant interaction between the type of surgery and alcohol use. Patients who underwent Roux-en-Y gastric bypass reported significantly greater alcohol use at 12 (P=0.048) and 24 (P=0.011) months compared with baseline. Alcohol use did not increase significantly in the patients who underwent adjustable gastric banding.

The authors acknowledged several limitations of the study, including reliance on self-reported substance use and missing data from one or more follow-ups for a majority of patients. Survey response rates declined from 61% at 1 month to 24% at 24 months.

"Despite these limitations, our study provides evidence that the frequency of substance use increased following weight-loss surgery," the authors wrote in conclusion. "More specifically, the frequency of alcohol use increased following laparoscopic Roux-en-Y gastric bypass surgery."

The authors had no disclosures.

Reviewed by Zalman S. Agus, MD Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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